Provider Demographics
NPI:1982477030
Name:PINE PEAK THERAPY LLC
Entity Type:Organization
Organization Name:PINE PEAK THERAPY LLC
Other - Org Name:PINE PEAK AUDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:VIG
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:218-435-1210
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-0300
Mailing Address - Country:US
Mailing Address - Phone:218-435-1210
Mailing Address - Fax:
Practice Address - Street 1:103 1ST ST W
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1212
Practice Address - Country:US
Practice Address - Phone:218-431-0009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-31
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty